Phase IV CAQH CORE Operating Rules

Transcription

1 Phase IV CAQH CORE Operating Rules Implementation Value Proposition and Infrastructure Requirements Friday, June 10 th, :00 3:00 PM ET

2 Logistics Presentation Slides & How to Participate in Today s Session Download a copy of today s presentation slides at caqh.org/core/events - Navigate to the Resources section for today s event to find a PDF version of today s presentation slides - Also, a copy of the slides and the webinar recording will be ed to all attendees in the next 1-2 business days Click to add title The phones will be muted upon entry and during the presentation portion of the session At any time throughout the session, you may communicate a question via the web Questions can be submitted at any time with the Questions panel on the right side of the GoToWebinar desktop 2

3 Session Outline Welcome and Introduction Case Study with Humana Inc. A Phase IV CAQH CORE Operating Rules Early Implementer Benefits and Value Proposition for Implementation Free CORE Implementation Resources and Phase IV Certification Infrastructure Requirements Audience Q&A 3

4 Phase IV CAQH CORE Operating Rules: Early Implementer Case Study Kim Peters Process Owner, Provider Process Implementation, Humana Inc. 4

5 Who is Humana? Longevity: Celebrating over 50 years. Lifelong Well-being: Dedicated to providing solutions to enhance the wellness of each employee no matter what stage of life. Financially Stable: 58 on Fortune 500 with revenues of $54 billion; total assets of approximately $25 billion. Multi-faceted: Commercial, Individual, Medicare, Medicaid, Specialty Benefits and Well-being Solutions. Personal: Dedicated to providing personalized and exceptional service at every level. 5

6 Why is Humana Implementing the Phase IV CAQH CORE Operating Rules? Supports Administrative Simplification. Strives to be a leader to drive healthcare to a new paradigm. Humana believes in the industry-led process that culminated in the development of the Phase IV CAQH CORE Operating Rules. 6

7 Why is Humana a Phase IV Certification Beta Tester? One of the first entities to achieve Phase I-II CORE Certification. The first health plan to achieve Phase III CORE Certification. Humana wants to lead the path in achieving Phase IV CORE Certification. 7

8 Polling Question #1 Which stage(s) of implementing the Phase IV CAQH CORE Operating Rules are you voluntarily planning to complete in 2016? (Select all that apply) 1. Internal Education and Awareness 2. Analysis and Planning/Systems Design 3. Systems Implementation/Integration and Testing 4. Deployment/Maintenance 5. We do not plan to start voluntary implementation in

9 Phase IV CAQH CORE Operating Rules: Benefits and Value Proposition for Implementation Robert Bowman CAQH CORE Associate Director 9

10 Implementing the Phase IV CAQH CORE Operating Rules in 2016 By voluntarily implementing the Phase IV CAQH CORE Operating Rules in 2016, your organization will: Establish your leadership in the industry as an early adopter. Determine your own timeline rather than a mandated one. Demonstrate your organization's commitment to administrative simplification. Build on work that has been implemented in previous Phases. Early adoption means efficiencies for you and your customers will be realized sooner. 10

11 Implementing Phase IV CAQH CORE Operating Rules Message to Business Level Decision-Makers & Executives The Phase IV CAQH CORE Operating Rules Improve Business Processes by - Applying consistent infrastructure across transactions to achieve economies of scale - Recognizing that the steps in financial management are a set of interrelated processes - Addressing the interrelatedness of clinical and financial data - Moving to electronic processes - Eliminating redundancy in financial processes - Ensuring processes support efficiency gains and greater transparency for patients 11

12 Value Proposition: Cost Reductions and Increased Efficiency Rule requirements will save time and money Response time and acknowledgment requirements ensure nothing falls into a black hole and that providers are informed. Less time is spent verifying information over the phone. Providers can immediately learn if their claim submissions were successfully received by plan and moved into the adjudication system. Providers can immediately learn whether the plan has received and is reviewing prior authorization request. CAQH CORE safe harbor ensures providers can connect online for all of their transactions using their preferred connection method. Providers can improve coordination of benefits (COB) through more timely eligibility information from health plan and knowledge of plan s requirement for COB in their companion guide. Health plans can build on investments already made in infrastructure for eligibility, claim status, EFT and ERA. 12

13 Value Proposition: Improved Customer Service Rule requirements will improve customer satisfaction Safe harbor connectivity allows you to conduct the transactions with any trading partner upon request reducing trading partner onboarding. Use of the CORE Companion Guide Template makes it easier to engage trading partners. Timely data will lead to faster treatment and consolidation of clinical and financial transactions improving patient satisfaction. 13

14 Value Proposition: Improve Quality Rule requirements will improve quality by reducing errors and confusion Use of digital certificate authentication improves security. Providers are assured that PHI is transmitted through secure connectivity that meets the national standards. Real time connectivity requirement specification lays the tracks for future development. Health plans have a common set of infrastructure rules across all transactions on which providers can rely including: - Secure connectivity - Standardized use of acknowledgements which decreases burden to help desks - Consistency in companion guide formats across all transactions - Consistency in system availability across all transactions - Common expectations around processing mode and response times for each transaction 14

15 Polling Question #2 What are the anticipated benefits to your organization s implementation of the Phase IV CAQH CORE Operating Rules? (Select all that apply) 1. Work flow improvements 2. Cost reductions 3. Improved services 4. Don t know 5. Not applicable 15

16 Phase IV CAQH CORE Operating Rules: Implementation Resources and Certification Tyler Schultz CAQH CORE Senior Project Associate 16

17 Phase IV CAQH CORE Operating Rule Implementation Challenges Challenges: Busy Team, Competing Priorities Industry Regulatory Fatigue Many Deliverables Competing Resources CAQH CORE Commitment to Operating Rule Implementation: The CAQH CORE Implementation Resources webpage has a number of resources and tools available at no cost to assist entities with implementation of the CAQH CORE Operating Rules. Additionally, CAQH CORE offers CORE Certification to entities that create, transmit or use the administrative transactions addressed by the CAQH CORE Operating Rules. CORE Certification means an entity has demonstrated that its IT system or product is operating in conformance with a specific phase(s) of the CAQH CORE Operating Rules and underlying standards. 17

18 Phase IV CAQH CORE Analysis & Planning Guide Understand the applicability of rules to various trading partners As with previous Phases, CAQH CORE now has an Analysis & Planning Guide for the Phase IV CAQH CORE Operating Rules Planning Guide should be used by project staff to: Understand applicability of the Phase IV CAQH CORE Operating Rule requirements to organization s systems and processes that conduct the transactions. Identify all impacted external and internal systems and outsourced vendors that process the transactions. Conduct detailed rule requirements gap analysis to identify system(s) that may require remediation and business processes which may be impacted. 18

19 Stakeholder & Business Type Evaluation Know what aspects of your business or outsourced functions are impacted Key Takeaway: Coordinate planning and implementation. Determine your stakeholder type and which Phase IV rules apply to you and your trading partners. 19

20 System Inventory & Impact Assessment Worksheet Identify and inventory all impacted systems and products Key Takeaway: Understand how many of your systems/ products are impacted by each Phase IV rule requirement and with which vendors you will need to communicate and coordinate. 20

21 Gap Analysis Worksheet Determine the level of system remediation needed to adopt the rule requirements Key Takeaway: Understand the level of system remediation necessary for adopting the business and technical requirements of the Phase IV CAQH CORE Operating Rules. 21

22 Phase IV CAQH CORE Operating Rules - Frequently Asked Questions (FAQs) CAQH CORE FAQ Website Includes more than 100 Phase IV CAQH CORE Operating Rule FAQs, from general concepts to technical questions More FAQs are added every month! Part E: Phase IV CAQH CORE Operating Rules I. Overview of Phase IV CAQH CORE Operating Rules II. CAQH CORE 450: Health Care Claim (837) Infrastructure Rule III. CAQH CORE 452: Health Care Services Review - Request for Review and Response (278) Infrastructure Rule IV. CAQH CORE 454: Benefit Enrollment and Maintenance (834) Infrastructure Rule V. CAQH CORE 456: Premium Payment (820) Infrastructure Rule VI. CAQH CORE 470: Connectivity Rule VII. Resources for Implementing the Phase IV CAQH CORE Operating Rules 22

23 Voluntary CORE Certification Developed BY Industry, FOR Industry CORE Certification is the most robust and widely-recognized industry program of its kind. Its approach assures an independent, industry-developed confirmation of conformance with operating rules and underlying standards: Requirements are developed by broad, multi-stakeholder industry representation through transparent discussion and polling process. Required conformance testing is conducted by third party testing vendors that are experts in EDI and testing. CAQH CORE serves as a neutral, non-commercial administrator: - Authorizes the conformance testing vendors. - Reviews and approves the Certification applications and conformance test reports before Certification Seal is awarded. 23

24 Voluntary CORE Certification is Good for Business HEALTH PLANS PROVIDERS CLEARINGHOUSES VENDOR SOLUTIONS Conduct secure, timely, and streamlined electronic transactions. Eliminate time-consuming calls/paperwork Add value for current customers and attract new customers. Demonstrate conformance with federally mandated operating rules and underlying standards. Increase patient satisfaction through efficient patient services Meet expectations: CORE Certification is becoming a trading partner contract expectation by health plans and providers. Show that you are maximizing the efficiencies afforded by the operating rules and underlying standards. Show that you are maximizing the efficiencies afforded by the operating rules and underlying standards. Guarantee that your systems, products, or services are conformant with the operating rules and underlying standards. Help your customers: CORE Certification allows your customers the value-add of drafting behind your certification and also becoming CORE-certified. Achieve these goals through CORE Certification, a process that uses industry-developed conformance requirements, a third-party tester, and a neutral, non-commercial administrator. 24

25 Phase IV CAQH CORE Operating Rule Implementation Approach Use CORE Analysis & Planning Guide resources 1 Engage Internal Resources Assess Rules Perform Analysis Remediate Products Engage Trading Partners Coordinate Certification Planning Perform Testing File for CORE Certification Share project plans & timing; sign/submit CORE Certification Pledge 25

26 Phase IV CAQH CORE Operating Rule Implementation Keys to Success Establish Open Communication with Trading Partner(s) - Continuation of CORE Certification relationship established in prior Phases Have the Right Plan Set Yourself up for Success! - Start with the Certification goal in mind - Document all necessary actions, not just testing - Base your approach on CAQH CORE implementation tools - Open and frequent communication with trading partners regarding planning and testing approaches 26

27 Polling Question #3 Which of the following is the biggest challenge to your organization s implementation of the Phase IV CAQH CORE Operating Rules? 1. Fully understanding the requirements of the Phase IV CAQH CORE Operating Rules 2. Having enough resources (time/staff/$) for implementation 3. Decision makers in my organization have not given the go ahead 4. No major challenges 5. Not applicable 27

28 Phase IV CAQH CORE Operating Rules: Infrastructure Requirements Robert Bowman CAQH CORE Associate Director 28

29 Complete Set of Phase IV CAQH CORE Operating Rules Phase IV CAQH CORE Operating Rules Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule v4.0.0 Today s Focus Phase IV CAQH CORE 452 Health Care Services Review Request for Review and Response (278) Infrastructure Rule v4.0.0 Phase IV CAQH CORE 454 Benefit Enrollment and Maintenance (834) Infrastructure Rule v4.0.0 Phase IV CAQH CORE 456 Premium Payment (820) Infrastructure Rule v4.0.0 Phase IV CAQH CORE 470 Connectivity Rule v

30 Scope of Phase IV CAQH CORE Rule Requirements Reminder: Health Claims Attachments transaction not included; there is no formal HIPAA Health Claims Attachments standard(s) Infrastructure Requirement Prior Authorization Claims Enrollment/ Disenrollment Premium Payment Processing Mode Batch OR Real Time Required Batch Required; Real Time Optional Batch Required; Real Time Optional Batch Required; Real Time Optional Batch Processing Mode Response Time If Batch Offered X X X Batch Acknowledgements If Batch Offered X X X Real Time Processing Mode Response Time Real Time Acknowledgements If Real Time Offered If Real Time Offered If Real Time Offered If Real Time Offered If Real Time Offered If Real Time Offered If Real Time Offered If Real Time Offered Safe Harbor Connectivity and Security X X X X System Availability X X X X Companion Guide Template X X X X Other N/A Include guidance for COB in companion guide Timeframe requirements to process data after successful receipt and verification of transaction Timeframe requirements to process data after successful receipt and verification of transaction X = Required 30

31 Batch Processing Mode Response Time Requirements Batch Processing Mode Response Time requirements specify the overall length of elapsed time from when a transaction is sent to a health plan and when the acknowledgement(s) or response to the transaction is available for pick up (retrieval) by the sender. 1 2 Sent by 9 pm ET on a business day Available by 7 am ET within specified # of business days Applicability of Requirements Infrastructure Requirement X12N v X12N v X12N v X12N v Batch Processing Mode Response Time X If Batch Offered X X 31

32 Batch Acknowledgement Requirements ASC X12N v Transaction ACS X12N v Transaction ACS X12N v & 820 Transaction Health plan must return an ASC X12C v to indicate the Functional Group was accepted, accepted with errors, or rejected and to specify the Transaction Set was accepted, accepted with errors, or rejected A health plan must acknowledge each claim received using the ASC X12N v CA unless previous processing resulted in rejection of the Interchange or a Transaction Set in a Functional Group An entity must return an ASC X12C v to indicate the Functional Group(s) was accepted, accepted with errors, or rejected and to specify the Transaction Set was accepted, accepted with errors, or rejected A health plan must return an ASC X12C v to indicate the Functional Group is accepted, accepted with errors, or rejected Applicability of Requirements Infrastructure Requirement X12N v X12N v X12N v X12N v Batch Acknowledgement X If Batch Offered X X 32

33 Real Time Processing Mode Response Time Requirements Real Time Processing Mode Response Time requirements specify the overall length of elapsed time from when a provider/health plan purchaser (sender) sends a transaction to a health plan and the related response transaction is received by the sender. 20 Seconds Round Trip Max Response Time Applicability of Requirements Infrastructure Requirement X12N v X12N v X12N v X12N v Real Time Processing Mode Response Time If Real Time Offered If Real Time Offered If Real Time Offered If Real Time Offered 33

34 Real Time Acknowledgement Requirements When a claim is submitted in real time processing mode without adjudication: ASC X12N v Transaction ASC X12C v Transaction ACS X12N v & 820 Transaction A health plan must return an ACS X12C v to indicate Functional Group is rejected A health plan must return an ASC X12N v CA to indicate Functional Group is accepted or accepted with errors A health plan must return an ASC X12C v to indicate Functional Group was rejected A health plan must return an ASC X12C v to indicate the Functional Group is accepted, accepted with errors or rejected Infrastructure Requirement Real Time Acknowledgement Applicability of Requirements X12N v If Real Time Offered X12N v If Real Time Offered X12N v If Real Time Offered X12N v If Real Time Offered 34

35 Safe Harbor Connectivity & Security Requirements Safe Harbor Health Plan Provider Enables trading partners to use different communications and security methods than what is specified in rule: HIPAA covered entities must support CORE Connectivity Rule requirements for real time and batch processing modes. Can offer other communications and security methods. Does not require trading partners to de-implement any existing connectivity methods not compliant with CORE Connectivity Rule. 35

36 System Availability Requirements System Availability requirements establish the amount of time a system must be available to process the specified transactions: Minimum of 86 percent system availability (per calendar week) Publish regularly scheduled downtime Provide one week advance notice on non-routine downtime Provide information within one hour of emergency downtime Infrastructure Requirement Applicability of Requirements X12N v X12N v X12N v X12N v System Availability X X X X 36

37 Companion Guide Requirements When an entity publishes a Companion Guide, the CAQH CORE Companion Guide requirements establish the format and flow of Companion Guides. Format & Flow Specified in Template Introduction Getting Started Testing with the Payer Connectivity with Payer/Communications Contact Information Control Segment/Envelopes Payer Specific Business Rules and Limitations Acknowledgements and/or Reports Trading Partner Agreements Transaction Specific Information Applicability of Requirements Infrastructure Requirement Companion Guide X12N v X12N v X12N v X12N v X X X X 37

38 Unique Phase IV Infrastructure Requirements Phase IV Operating Rule Health Care Claim Infrastructure Rule Benefit Enrollment and Maintenance Infrastructure Rule Payroll Deducted and Other Group Premium Payment for Insurance Products Infrastructure Rule Unique Phase IV Infrastructure Requirement (e.g. not included in previous CAQH CORE Rules) The receiver (defined as the HIPAA-covered provider or its agent) of ASC X12C v transaction and ASC X12N v CA transaction is required to: Process any ASC X12C v or ASC X12N v CA transaction within one business day of its receipt. Recognize all error conditions that can be specified using all standard acknowledgements named in this rule and to pass all such error conditions to the end user as appropriate OR to display to the end user text that uniquely describes the specific error condition(s), ensuring that the actual wording of the text displayed accurately represents the error code and the corresponding error description specified in the related ASC X12 acknowledgement specification without changing the meaning and intent of the error condition description. A HIPAA-covered health plan or its agent must process benefit enrollment/maintenance data by its system within five business days following the receipt and validation of the data. A HIPAA-covered health plan or its agent must process the Payroll Deducted and Other Group Premium Payment for Insurance Products data by its internal application system within five business days following the successful receipt and validation of the data. 38

39 Audience Q&A Please submit your questions Enter your question into the Questions pane in the lower right hand corner of your screen. You can also submit questions at any time to Reminder - Download a copy of today s presentation slides at caqh.org/core/events Navigate to the Resources section for today s event to find a PDF version of today s presentation slides Also, a copy of the slides and the webinar recording will be ed to all attendees in the next 1-2 business days 39

40 Key Takeaways There is value in planning for implementation now. Be a leader in the healthcare industry. The Phase IV CAQH CORE Voluntary Operating Rules build upon Phases I-III. Phase IV CAQH CORE Operating Rules are a first step for these transactions prior authorization, claims, enrollment/disenrollment and premium payment and establish key infrastructure; data content will be addressed in future phases. CAQH CORE is available to answer your questions and provide implementation resources for the Phase IV CAQH CORE Operating Rules as well as for Phases I- III. 40

41 Upcoming CAQH CORE Education Sessions Certifying Local Government Plans: Voluntary CORE Certification Webinar with San Francisco Health Plan WEDNESDAY, JUNE 29, PM ET To register, please go to 41

42 Engage With Us! Visit us at the CAQH CORE Website or contact us at Participate in the CAQH CORE Code Combinations Task Group (CCTG) or the Enrollment Data Task Group Explore Voluntary CORE Certification Become a CAQH CORE Participating Organization Register for upcoming webinars Dedicated webpages: Code Combination Maintenance EFT/ERA Enrollment Maintenance Voluntary CORE Certification CAQH CORE Phase IV Operating Rules 42

43 Thank you for joining us! Website: 43